Computer Programs for Cognitive—Behavior Therapy

Computer Programs forCognitive–Behavior Therapy

Jesse H. Wright and D. Kristen SmallKeywords: computers, computer-based therapy, treatment fordepression

The first computer programs for cognitive–behavior therapy(CBT) were developed in the 1980s by teams of investiga-tors in the United Kingdom (Carr, Ghosh, & Marks, 1988;Ghosh, Marks, & Carr, 1984) and the United States (Selmi,Klein, Greist, & Harris, 1982; Selmi, Klein, Greist, Sorrell,& Erdman, 1990). Using the computer technology of thetime, these researchers produced programs that relied onwritten text, checklists, and multiple-choice questions forcommunication with the patient. More recently developedcomputer tools for CBT have incorporated multimedia, vir-tual reality, hand-held devices, or other methods to rapidlyengage the user and stimulate learning (Newman, Kenardy,Herman, & Taylor, 1997; Rothbaum et al., 1995; Rothbaum,Hodges, Ready, Graap, & Alarcon, 2001; Wright & Wright,1997; Wright et al., 2002). Computer programs have beentested and found to be useful for a variety of Axis I disordersincluding depression, simple phobia, agoraphobia, andPTSD (Ghosh et al., 1984; Gruber, Moran, Roth, & Taylor,2001; Proudfoot et al., 2003; Rothbaum et al., 1995, 2001.

Some of the potential advantages of using computerprograms as a component of psychotherapy are that theymay provide innovative and effective learning experiences,reduce the cost of treatment, increase access to CBT, andhelp therapists and patients reach treatment goals more rap-idly or efficiently (Greist, 1998; Marks, Shaw, & Parkin,1998; Wright & Wright, 1997). Because computers have theability to store and analyze large amounts of data, give sys-tematic feedback, and measure progress, they may extendthe ability of the clinician to monitor and direct the courseof therapy. In addition, computer programs have the capac-ity to immerse the patient in learning situations that couldnot be easily re-created in standard, clinician-administeredtherapy. For example, virtual reality can be used to effec-tively mimic the cues of feared situations, while multimediaprograms can use emotionally charged video and audio tostimulate patient cognitions.

Computer tools for psychotherapy also have significantliabilities in comparison to human therapists. Early in thehistory of computer-assisted therapy, there were attempts todevelop programs that conducted interviews using typicaltherapist–patient dialogue (often termed “natural language”)(Colby, Watt, & Gilbert, 1966; Weizenbaum, 1966).However, these efforts were fraught with problems such asmiscommunications and negative reactions of patients(O’Dell & Dickson, 1984). Thus, developers of computerprograms for CBT have steered away from “natural lan-guage” programming. Instead of trying to replicate thera-pist–patient communication, authors of CBT programs havefocused on using the unique strengths of computers to pro-vide psychoeducation, involve patients in self-directedexposure, promote cognitive restructuring, and encourageuse of other CBT methods.

CBT computer programs are typically designed byhighly experienced cognitive–behavior therapists and con-tain the core methods of empirically studied treatments.They provide supportive feedback to users, reinforce self-monitoring, and assign homework. However, they cannot beprogrammed (at least with current technology andresources) to have the wisdom, flexibility, creativity, andempathy of human therapists (Nadelson, 1987; Wright &Wright, 1997). Most programs are designed to deliver spe-cific elements of CBT for a targeted disorder or symptom(e.g., exposure therapy for phobia, cognitive and behavioralinterventions for depression) and thus are not able to per-form full diagnostic assessments, evaluate suicide risk, ordeliver treatment for a wide range of problems. Because ofthese limitations, clinical applications of computer-assistedCBT typically include assessment, monitoring, and direc-tion from a clinician.

All computer programs developed to date for CBThave been designed to reduce therapist contact to somedegree. In some applications, the clinician’s involvementhas been limited to an initial assessment and minimal mon-itoring of a computer-based therapy intervention (Ghosh et al., 1984; Kenwright, Liness, & Marks, 2001; Selmi et al.,1990). However, many investigators have had more modestgoals of lowering the requirement for therapist time. Forexample, Newman et al. (1997) used a hand-held computerprogram to substantially reduce the number of cliniciansrequired for treatment of panic disorder. Some computerprograms have been produced in “Professional” and“Consumer” editions (Colby & Colby, 1990; Wright,Wright, & Beck, 2003). The professional edition is intendedfor use in clinical settings under the supervision of a thera-pist; the consumer version may be recommended for homeuse, much like self-help books are commonly used asadjuncts to CBT. The consumer versions are clearly labeledas products that are not to be used as a substitute for profes-sional diagnosis and treatment.

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The author may receive a portion of profits from sales of Good Days Ahead,a computer program described in this article. A portion of profits from salesof Good Days Ahead is donated to the Foundation for Cognitive Therapyand Research and the Norton Foundation.

Computer Programs for Cognitive—Behavior Therapy

Research studies on computer-assisted CBT havefound that computer programs are well accepted by patientsand are usually efficacious in treating symptoms (Greist,1998; Marks et al., 1998; Wright & Wright, 1997; Wright etal., 2002). Investigations reviewed below are limited tothose that involved the use of a computer to deliver a signif-icant element of CBT for depression, anxiety disorders, andeating disorders. Programs developed for habit control andsex counseling are not included because they were notdesigned to augment or provide psychotherapy. Also, inter-active voice response (IVR) systems are not discussed.These interventions use an automated, computer-controlledtelephone system, in addition to manuals and videotapes, toprovide treatment (Griest et al., 2002; Osgood-Hynes et al.,1998). But, they do not utilize a computer interface to com-municate with patients.

An early prototype for computerized exposure therapyfor snake phobia was reported in 1970 by Lang, Melhamed,and Hart; but the first controlled trial of computer programdesigned for a wide range of phobias did not appear untilover a decade later (Ghosh et al., 1984). This software wasbased on the book Living with Fear (Marks, 1978). A text-only format was used to provide psychoeducation on expo-sure therapy, generate a problem list text, and encourageusers to become involved in self-directed exposure. Twostudies with different versions of this software found thatcomputerized therapy was equivalent to standard clinician-administered exposure therapy (Carr et al., 1988; Ghosh et al., 1984).

Another early computer program for CBT was found tobe effective in the treatment of depression (Selmi et al.,1982, 1990). This program included questionnaires, caseillustrations, and multiple-choice questions to convey the basics of CBT. Because it was produced for the DOS operating system and relies completely on text for communication with patients, it is not being used in contemporary clinical practice. In a study with mildly tomoderately depressed patients, computer-assisted therapywith the Selmi et al. (1990) software was observed to beequal to standard CBT and superior to a wait-list controlcondition.

The only investigation of computer-assisted therapy fordepression or anxiety disorders that did not show positiveresults was reported by Bowers et al. (1993) who tested theusefulness of Overcoming Depression (Colby & Colby,1990; Colby, 1995) with depressed inpatients. TheOvercoming Depression software has a few components thatintroduce cognitive and behavioral concepts; but unlikemore fully developed programs for CBT (e.g., Proudfoot et al., 2003; Selmi et al., 1982, 1990; Wright, Salmon,Wright, & Beck, 1995; Wright et al., 2002, 2003), this program does not present comprehensive or detailed cogni-tive–behavioral interventions. Also, Overcoming Depression

is the only currently available software that includes a “natural language” module. This part of the programappeared to confuse depressed inpatients in a controlledstudy (Bowers et al., 1993; Stuart & LaRue, 1996). In theinvestigation by Bowers et al. (1993), computer-assistedtreatment did not significantly improve outcome in hospital-ized patients who were receiving other treatments includingmedications and milieu therapy.

More recently developed multimedia programs forcomputer-assisted therapy have fared much better in ran-domized, controlled trials. For example, Wright et al. (1995,2001, 2002) have reported on the development and testing ofsoftware that uses multimedia and a variety of interactiveexercises to assist clinicians in treatment with CBT. Thiscomputer program (Good Days Ahead), like other newermultimedia software produced by Proudfoot et al. (Beatingthe Blues, 2003), is primarily targeted at depression, but alsocovers core CBT methods that may be helpful to patientswith anxiety symptoms.

Studies with the Wright et al. program found high levels of user satisfaction with the software, efficacy thatwas equal to standard CBT, and robust effects in improvingmeasures of automatic thoughts and dysfunctional attitudes(Wright et al., 2001, 2002). In an investigation of medication-free patients with major depressive disorder,both computer-assisted CBT and standard CBT were supe-rior to a wait list control group in relieving symptoms ofdepression, even though therapist contact was substantiallyreduced in the computer-assisted therapy condition. GoodDays Ahead was originally produced in laser disk format butis now available on DVD-ROM.

Proudfoot et al. (2003) have reported that another multimedia program (Beating the Blues) was effective in thetreatment of a group of primary care patients with depres-sion, anxiety, or mixed depression and anxiety. Subjects inthis study were randomly assigned to receive treatment as usual (TAU) from their primary care practitioner or TAU plus Beating the Blues. Patients who used the multi-media software had significantly better outcomes than those who received standard treatment alone. Beating the Blues was developed and tested in the United Kingdom. It includes video illustrations of fictional characters, voice-overs, animations, and interactive exercises that teach CBTskills.

Virtual reality programs have been developed forheight phobia (Rothbaum et al., 1995), fear of flying(Muehlberger, Herrmann, Wiedemann, Ellgring, & Pauli,2001; Rothbaum et al., 2000), claustrophobia (Botella, Villa,Banos, Perpina, & Garcia-Palacios, 2000; Wiederhold &Wiederhold, 2000), social phobia (North, North, & Coble,1998; Petraub, Slater, & Barker, 2001; Wiederhold &Wiederhold, 2000), spider phobia (Carlin, Hoffman, &Weghorst, 1997), agoraphobia (Wiederhold & Wiederhold,

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Computer Programs for Cognitive—Behavior Therapy

2000), PTSD (Rothbaum et al., 2001), and body imageproblems in persons with binge eating disorder (Riva,Bacchetta, Baruffi, & Molinari, 2002). Applications of virtual reality technology focus on producing computer-generated simulations of feared objects, situations, orimages that can be used for exposure-based interventions.Three-dimensional computer graphics, head sets, speakers,body tracking instruments, and other sensory input devicesare used to immerse patients in realistic scenes such asglass-enclosed elevators.

In a preliminary study, Rothbaum et al. (1995)observed that virtual reality exposure therapy (VR) forheight phobia was more effective than a wait-list controlcondition. This research group also has reported that VRwas equal to standard exposure therapy and superior to await list in helping persons with fear of flying (Rothbaum et al., 2000). Another VR application was evaluated in asmall controlled study that compared a multidimensionaltreatment approach (including a virtual reality component)with group CBT for binge eating disorder (Riva et al., 2002).Subjects in this investigation also received dietary counsel-ing and physical exercise. There were no significant differ-ences found between the groups in reducing binge eatingbehavior, but patients treated with VR had significantlygreater improvement in measures of body satisfaction andself-efficacy (Riva et al., 2002).

Hand-held computers have provided another format for using computer technology to assist therapists andpatients. Newman et al. (1997) developed a method of usingpalmtop computers to shorten CBT for panic disorder bygiving computer-based instructions on self-monitoring,exposure and response prevention, breathing training, andpositive self-statements. In a study with 20 patients, bothcomputer-assisted CBT (4 sessions with a clinician plushand-held computer program) and standard CBT (12 ses-sions with a clinician) were found to be effective. StandardCBT was superior to computer-assisted CBT on some meas-ures at the end of treatment, but both forms of therapy wereequally effective at the follow-up assessment.

Gruber et al. (2001) have reported similar findings in a study of a hand-held computer program for social phobia. Their computer program was designed to assist ingroup cognitive therapy by reinforcing the material taught in group sessions, giving prompts to confront fears, involv-ing users in exercises to modify automatic thoughts, andproviding progress reports. In a study comparing standardgroup CBT and computer-assisted CBT (with reduced therapist contact), there were advantages on some measuresfor standard therapy at the end of treatment; but at the follow-up assessment, no differences were found betweenthe treatments (Gruber et al., 2001).

Another investigation of computer-assisted CBT testedthe usefulness of Fear Fighter, an updated version of a text-based program for phobias (Ghosh et al., 1984; Marks,1978). The software has been upgraded to include graphicillustrations and voiceovers, but does not include all featuresof fully developed multimedia programs (e.g., Proudfoot et al., 2003; Wright et al., 1995, 2002). A preliminary,uncontrolled study found that computer-assisted therapywith Fear Fighter reduced symptoms of agoraphobia as effectively as standard clinician-administered CBT(Kenwright et al., 2001).

Research on computer-assisted CBT has demonstratedthat computer technology has the potential to increase theefficiency of treatment, decrease cost, and improve access to empirically tested interventions. However, there havebeen a limited number of well-controlled investigations, andmost studies have utilized a small number of subjects.Larger controlled studies and replications in multiple set-tings are clearly needed. Broader availability of highlyrefined programs with demonstrated efficacy, greater use ofcomputers throughout society, and pressures to developcost-effective treatments could lead to the future growth ofcomputer-assisted psychotherapy.

See also: Computers and technology

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Computers and Technology

Bruce M. GaleKeywords: computers, technology, virtual reality, teletherapy, distancelearning

Evolutionary rather than revolutionary, use of technologyhas built on existing theories supporting cognitive–behav-ioral assessment and treatment. Just as radiologists and sur-geons found that new technology tools led to moreefficacious and novel treatments in their fields, mentalhealth professionals have been discovering innovativeassessment and intervention techniques. By the late 1990s,many of the barriers preventing widespread use of technol-ogy in clinical applications had largely disappeared. This ledto the expansion and “trickle down” effect where technologytools were no longer the domain of well-funded laboratoriesat major universities, but could now be found on portablesystems used by clinicians in small clinic and private prac-tice settings. Equipment and software that was unheard of in 1985, and that cost $50,000 in 1995, could now be purchased for under $5000.

Some of the earliest mainstream applications usingtechnology included the use of biofeedback. Colors and

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